Provider Demographics
NPI:1780670596
Name:BHATIA, SUMIT (MD)
Entity Type:Individual
Prefix:DR
First Name:SUMIT
Middle Name:
Last Name:BHATIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRAIDWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60408-1912
Mailing Address - Country:US
Mailing Address - Phone:815-390-7271
Mailing Address - Fax:
Practice Address - Street 1:170 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRAIDWOOD
Practice Address - State:IL
Practice Address - Zip Code:60408-1912
Practice Address - Country:US
Practice Address - Phone:815-390-7271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA223699207W00000X
IL036117968207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36117968Medicaid
IL36117968Medicaid